Apparatus for preparing statements

ABSTRACT

A process and apparatus for accurately recording medical and personal information obtained from a medical patient or a prescription customer, where the patient or customer is a member of an institutional health service program. A specially formed transparent matrix containing portions of a written blank format for the recording of information preprinted thereon is also adapted to hold identification and/or prescription information records in a proper place relative to the preprinted format. The matrix, with the identification and/or prescription record in place, is passed through a copying machine which prints out a form ready for use by the doctor, hospital, pharmacist or the like. The present method and apparatus prevents errors in transcribing information obtained from the patient or customer to the forms required to be submitted to the institutional health service program for repayment.

United States Patent Abrams APPARATUS FOR PREPARING STATEMENTS [52] US. Cl. 354/292; 355/79 [51] Int. Cl. G03B 15/00 [58] Field of Search 355/79; 354/292 References Cited UNITED STATES PATENTS 11/1967 Schulze...; ..355/79 9/1971 Anderson ..355/79 Primary Examiner-John M. Horan Attorney, Agent, or Firml-loward B. Rockman, Esq.

um um ABSTRACT A process and apparatus for accurately recording medical and personal information obtained from a medical patient or a prescription customer, where the patient or customer is a member of an institutional health service program. A specially formed transparent matrix containing portions of a written blank format for the recording of information preprinted thereon is also adapted to hold identification and/or prescription information records in a proper place relative to the preprinted format. The matrix, with the identification and/or prescription record in place, is passed through a copying machine which prints out a form ready for use by the doctor, hospital, pharmacist or the like. The present method and apparatus prevents errors in transcribing information obtained from the patient or customer to the forms required to be submitted to the institutional health service program for repayment.

12 Claims, 5 Drawing Figures PORT, ANNIE MA\ EGE- :xTENDzu CAR:

U.S. Patent Oct. 14, 1975 Sheet1of3 3,913,118

T S CARP exrmzs GRUUPOR DATE p m p CASE Flaw ION "0 IP 2 SEPT-9,1971 04 207 266 VENPORT, ANNIE M 2542 W. WARREN BLVD. cH|cA o, ILL? GIZ O AL CREDIT as: i

CIRTIFI OFFICE m INPATIENT HosPn ECE- EYTENDE RE H-PA E T NIH-NURSING HOME. L-OTHER 12kg US. Patent Oct. 14, 1975 Sheet 2 of 3 3,913,118

U.S. atent Oct. 14 1975 Shee 3 of 3 I HI CARD ED 70\ I I Is 0 RE F ra-R E aw CASE DE CHICAGO) LL T MMIE V V'AN T RRY I IHH' r w No.

NET CHARGE SPfld O ricc Prn/d hatge APPARATUS FOR PREPARING STATEMENTS The present invention relates to information recording apparatus and processes, and more particularly to a means and method for accurately recording medical, prescription, and personal information obtained from a medical patient, prescription customer, hospital patient or the like for the purpose of expediting accounting and bookkeeping procedures related to the medical treatment or prescription services furnished the patient or customer.

With the advent of social reforms in the area of medical care and treatment, the problems of accounting and bookkeeping relating to services performed by doctors, nurses, dentists, pharmacists, hospitals and the like have proportionately increased. Pursuant to these reforms, medical care is presently available to everyone regardless of his ability to pay for the services he receives. Legislation has been enacted which makes various local, state and national governmental and institutional agencies responsible for providing payment to doctors, nurses, dentists, pharmacists, hospitals and other medical facilities for services rendered to individuals covered by the medical protection plans in question. To receive payment in usual cases, the professional or institution providing the treatment or service must submit properly completed forms 'to the paying agency, which will then, upon approval, remit payment to the professional or institution.

The forms which are submitted for payment usually must include such information as the name and address of the individual who received the services, the cost of the services, the nature of the treatment received, and the name and address of the person or institution furnishing the medical services. In the case of prescription services, a copy of the prescription must be submitted. The governmental or institutional agency, upon receiving the form, scrutinizes it to determine that the services rendered are covered by the medical program in question, that the professional or institution performing the services is qualified to do so, and that the individual receiving the services is eligible to be cared for under the program. This information is processed by a staff of workers employed by the governmental or institutional agency.

In implementing these medical care programs, several governmental bodies have adopted a similar method of identifying those persons who are eligible to receive medical care at the behest of the public weal, and have established a quantum of forms which must be accurately completed before the professional or institution can receive payment for services rendered. Various public aid, welfare, medicaid, and medicare agencies and the like have issued identification cards to people and families on their rolls which serve to indicate to a hospital, doctor, pharmacist, or other service entity that the individual is entitled to medical care, and that the cost for that care will be borne by the institutional body which issued the identification card. The forms to be submitted for payment have, for the most part, been standardized and are made available to professionals and institutions. As expected, the preparation of the form can be a cumbersome and time consuming task.

Upon receiving medical aid, or having his prescription filled, the recipient must give all the personal information contained on his identification card to the supplier of the services. A problem arises when the information from the card is transcribed improperly, which will delay, and may even prevent payment to the professional or medical facility by the governmental or institutional agency. Therefore, it is important that the personal information of the recipient be correctly recorded by the supplier of the medical, prescription, or hospital services, and that this information is correctly transcribed on the forms submitted for payment.

It is apparant that when the information must be transcribed from an identification card in the recipients possession to the proper payment form, the possibility of error exists. Therefore, it is a primary object of the present invention to provide a means and method of preventing errors in transcribing information received from a recipient of medical, hospital, or prescription services under an institutional program.

It is a further object of the present invention to provide a means and method of insuring that one who furnishes medical care treatment or prescription or hospital services to an individual covered by an institutional program may receive personal information necessary for obtaining payment without going through the step of transcribing such information upon an additional form or paper.

It is also an object of the present invention to furnish a means and method whereby a doctor, pharmacist, hospital, or the like may pre-print the forms necessary to insure payment from institutional medical care programs whereby the forms when printed, will contain personal information about the patient or customer, and in the case of a prescription, a copy of the prescription itself. The pre-printed forms will also contain the blank spaces necessary to record all required additional information.

A further object ofthe present invention is to provide a transparent matrix pre-printed with portions of an information recording format, the matrix having means to hold information-bearing cards or papers in position relative to the pre-printed material to comprise a partially filled-out record form when reproduced on a blank sheet of paper.

Still another object of the present invention is to provide a means and method of recording information and preparing payment request forms for medical, pharmaceutical, and hospital services rendered which allows immediate and accurate transcription of personal information from an identification card to a printed record form.

An additional object on one embodiment of the present invention is to provide a means and method of preparing a prescription payment request form which contains, pre-printed, the personal information relative to the customer, an exact copy of the prescription, and the name of the physician issuing the prescription.

In a first embodiment of my invention, a transparent matrix is provided, having pre-printed thereon in permanent ink, or the like, portions ofa form for recording information to be submitted for payment to a medical program for professional services rendered to a member of the program. The matrix also includes means forming a pocket therein for receiving an identification card or other information-bearing form and to hold the form in position relative to the pre-printed material on the matrix such that the identification information appears through the transparent matrix at a prescribed location relative to the remainder of the form. When a patient or customers identification form is received, it is placed in the pocket of the matrix. The matrix is then fed through a standard copying machine, such as an electrostatic or thermal transfer copying machine, or the like. A facsimile of the printed material on the matrix, plus the information on the identification card will be reproduced on the copy paper, which now comprises a form for recording pertinent information regarding services rendered to the person who is already permanently identified on the form. The identification form is removed from the matrix and returned to the patient or customer. The matrix is now ready to be used to create a form for the next patient or customer.

In a second embodiment of my invention, the matrix also includes an additional pocket to receive a form upon which a prescription is written. This embodiment is specifically adapted to assist a pharmacist in preparing the medical program forms necessary to obtain repayment for prescription services rendered to a member of an institutional medical program. When the customers identification form and prescription order form are inserted in the matrix, and the entire assembly is passed through a copying machine, a form emerges containing pre-printed thereon the customers identification information, a copy of the prescription filled, and blank spaces for the recording of other pertinent information necessary for submittal to the institutional medical program for payment.

These and other objects of the present invention will become more readily apparent from reading the following specification in connection with the accompanying drawings wherein:

FIG. 1 illustrates the matrix comprising the first embodiment of the invention, showing the relative location of the identification form and the pre-printed material on the matrix;

FIG. 2 illustrates the matrix of the second embodiment of the invention, showing the relative position of the identification card, prescription form, and preprinted material on the matrix;

FIG. 3 illustrates the matrix of FIG. 2 with the identification card and prescription form removed from their respective pockets in the matrix;

FIG. 4 is an exploded rear view of the matrix and forms of FIG. 2, illustrating the manner of inserting the forms into the matrix; and

FIG. 5 is a detail view of the matrix, identification card, and prescription form of FIG. 2.

Referring now to the drawings, the matrix comprising the first embodiment of my invention is identified by the numeral 10. The matrix is composed of a transparent material, preferrably plastic, capable of having inked or other indelible materials permanently affixed to the surface thereof. A second piece of material 12, not necessarily transparent, is adhered to the upper portion of the underside of matrix (as viewed in FIG. 1) to form a pocket 14 beneath the top most portion of matrix 10. In the illustrated embodiment, material 12 is adhered to matrix 10 by means of a heat seal 16. However, it is contemplated that any known manner of forming pocket 14 may be utilized within the scope of the present invention.

The lower portion of transparent matrix 10 has printed matter 18 permanently affixed thereto. Printed matter 18 comprises a form having blank spaces 19 for recording information when copied on a sheet of paper, as will be described. Printed matter 18 may also include the name of the professional or medical facility rendering the service. While printed matter 18 can describe a variety of forms, in the first embodiment of my invention, the printed matter comprises a format which is to be completed by a doctor, hospital or the like who has furnished professional services to a member of an institutional health services program. The form must be submitted to the program, which in turn repays the doctor, hospital, etc. for the services rendered. The format of the form is usually prepared by the medical services program, and copies are furnished to interested persons.

Pocket 14 is adapted to receive and hold an identification form such as a card 20 carried by the member of the institutional medical services program. This card has printed thereon certain personal and medical information 22 about the member, such as name, address, program identification number, name of the particular program in which enrolled, plus any additional information deemed pertinent by the program.

When card 20 is inserted in pocket 14 of matrix 10, the identification information on the card is visible through the transparent surface of the matrix and is superimposed above the pre-printed matter 18 on the surface of the matrix. In accordance with my inventive concept, sufficient blank space is available above printed matter 18 such that the information on card 20 does not interfere or lie directly under any of printed material 18. With card 20 in place in pocket 14, a master form has been created which contains an individuals personal information, and a blank form adapted for recording information relative to the medical or other treatment or services rendered the individual.

The next step in utilizing my novel device and method is to print a paper form from the master composed of matrix 10 and form 20, properly'located relative to one another. This is accomplished by placing the master matrix and card combination on the exposure station of an electrostatic copier, for example, or by using the master combination to expose a piece of sensitized paper in a thermal copying machine. It is also within the scope of my invention to employ the master thus created to reproduce the image thereon using any known paper copier machine.

The duplicate of the master combination created by the copying machine will consist of a partially completed form, containing the identification of the individual treated, and blank spaces for the insertion of additional information describing the treatment afforded the individual as well as the cost of such treatment. When the blank spaces are completed, the form is transmitted to the institutional medical program indicated on identification card 20. Thus, it will be appreciated that the individualss personal information has been recorded on the proper payment form without the danger of error in transcribing information from card 20 to the completed form. Also, the person or facility offering the treatment need not maintain a bulky supply of repayment forms on hand. Thus, the danger of running out of forms is eliminated. It is apparent that the professional or medical facility can be furnished with a small quantity of master matrix devices 10 to create the forms required by different institutional programs from a single copying machine.

The above described forms, and procedure for preparing such forms, may additionally be utilized in the printing of medical or paramedical worksheets to assist in the ultimate computerized or manual preparation of statements. For example, the form generated by the presently disclosed method may consist of a worksheet upon which a medical laboratory technician, ambulance driver, or other medical or parmedical assistant records pertinent data relative to services rendered. This worksheet is then submitted to a billing agency, which prepares statements to be forwarded to the patient.

The second embodiment of my invention, which is illustrated in FIGS. 2 to 5, is particularly adapted to be used by pharmacists in preparing and completing forms authorizing payment for prescription medicine services rendered to members of an institutional medical program. Most institutional programs require that the form submitted by the pharmacist for payment include a copy of the prescription itself, as well as personal information pertaining to the customer, the name of the pharmacist, and the cost of the prescription services. To this end, the matrix of my first embodiment is modified to permit a personal identification form or card, and a copy of a prescription to be inserted in the matrix for preparation of the proper form using a copying machine as previously described.

Referring to FIGS. 2 to 5 there is shown a matrix 50 composed of transparent material, preferably plastic, capable of having inked or other indelible materials permanently fixed to the surface thereof. The upper portion 52 of matrix 50 extends outwardly from one edge of matrix 50 as illustrated at the left hand side of FIG. 2. A second piece of material 54, which may or may not be transparent, is adhered to the underside of matrix 50 beneath upper portion 52. The second piece of material 52 is adhered to two edges 56, 58 of upper portion 52 to form a pocket 60 by means of a heat seal 62 or any other suitable means.

Pocket 60 is adapted to receive and hold a form or card 64 which has imprinted thereon personal information 66 pertaining to an individual covered by an institutional medical program. The written material 66 on card 64 is visible through the transparent surface of matrix 50 when card 64 is inserted in pocket 60.

Matrix 50 has permanently printed thereon written material 68 in the nature of blank spaces for recording information such as the number of the prescription, the item number and the quantity of items furnished.

The lower portion 70 of matrix 50 has attached thereto a third piece of material 72, not necessarily transparent, which is adhered to matrix 50 along two edges thereof by means of heat seal 62 or any other suitable means of adherence. Third piece of material 72 forms an additional pocket 74 in matrix 50 which is adapted to receive and hold a standard prescription order form 76, upon which is written the prescription 78 to be filled by the pharmacist.

FIG. 4 illustrates how the identification card 64 and prescription order form 76 are inserted in the pockets 60 and 74, respectively, of matrix 50. When identification card 64 and prescription order form 76 are properly located in pockets 60 and 74, the relative position of the printed material on each of these forms and the written material 68 on matrix 50 is such to form a master for preparing a form which contains (1) the personal identification of the prescription customer, including the name of the medical program in which he or she is enrolled, (2) a space in which to record information as to the order number, item number and quantity of the prescription medicine furnished to the customer, and (3') a copyof the pr'escription as written by the physician, including'the identification of the physician issuing the prescription. With this master, a form is prepared on a sheet of paper by using a standard copying machine ofthe type previously described in accordance with the steps and procedures set forth in the foregoing description of the first embodiment of my invention. The form, as printed from the master, is completed by the pharmacist, and submitted to the institutional program for payment.

It should be understood that while I have described and illustrated preferred embodiments of my invention in connection with specific apparatus and methods, it is to be clearly understood that this description is made only by way of example, and not as a limitation on the scope of my invention.

I claim:

1. An apparatus for preparing a master information recording form adapted to be processed through a copying machine to produce an information recording document comprising:

a matrix composed of transparent material;

printed matter permanently affixed to one surface of said transparent material for providing a printed form describing said information recording document and providing at least one space which must be completed;

a second material adhered to said transparent material to form a pocket in said matrix at a location which completes said printed form;

said pocket adapted to receive a first information bearing form juxtaposed over said printed form.

2. The apparatus of claim 1 wherein the information recording document is a form to be completed by one furnishing prescription medicine services to an individual.

3. The apparatus of claim 1 wherein said information bearing form comprises an institutional medical program personal identification card.

4. The apparatus of claim 1 wherein said transparent material is plastic.

5. The apparatus of claim 1 wherein the information on said information bearing form is visible through said transparent material when said information bearing form is located in said pocket.

6. The apparatus of claim 1 wherein said printed matter on said one surface includes a space whereby said information on said first information bearing form is visible in said space when said first information bearing form is located in said pocket.

7. The apparatus of claim 1 wherein said second material is adhered to said transparent material along two intersecting edges thereof, whereby said pocket is formed by said intersecting edges and said materials.

8. The apparatus of claim 1 wherein there are at least two of said spaces which must be completed:

a third material adhered to said transparent material to form a second pocket in said matrix over the second of said spaces which are to be completed,

said second pocket adapted to receive a second information bearing form.

9. The apparatus of claim 8 wherein said second information bearing form comprises a prescription medicine order form.

mation on said second information bearing form is visible through said second space when said second information bearing form is positioned in said second pocket.

12. The apparatus of claim 8 wherein said third material is adhered to said transparent material along two intersecting edges thereof, whereby said second pocket is formed by said intersecting edges and said materials. 

1. An apparatus for preparing a master information recording form adapted to be processed through a copying machine to produce an information recording document comprising: a matrix composed of transparent material; printed matter permanently affixed to one surface of said transparent material for providing a printed form describing said information recording document and providing at least one space which must be completed; a second material adhered to said transparent material to form a pocket in said matrix at a locatioN which completes said printed form; said pocket adapted to receive a first information bearing form juxtaposed over said printed form.
 2. The apparatus of claim 1 wherein the information recording document is a form to be completed by one furnishing prescription medicine services to an individual.
 3. The apparatus of claim 1 wherein said information bearing form comprises an institutional medical program personal identification card.
 4. The apparatus of claim 1 wherein said transparent material is plastic.
 5. The apparatus of claim 1 wherein the information on said information bearing form is visible through said transparent material when said information bearing form is located in said pocket.
 6. The apparatus of claim 1 wherein said printed matter on said one surface includes a space whereby said information on said first information bearing form is visible in said space when said first information bearing form is located in said pocket.
 7. The apparatus of claim 1 wherein said second material is adhered to said transparent material along two intersecting edges thereof, whereby said pocket is formed by said intersecting edges and said materials.
 8. The apparatus of claim 1 wherein there are at least two of said spaces which must be completed: a third material adhered to said transparent material to form a second pocket in said matrix over the second of said spaces which are to be completed, said second pocket adapted to receive a second information bearing form.
 9. The apparatus of claim 8 wherein said second information bearing form comprises a prescription medicine order form.
 10. The apparatus of claim 8 wherein the information on said second information bearing form is visible through said transparent material.
 11. The apparatus of claim 8 wherein said printed matter on said one surface includes a first space disposed thereon whereby said information on said first information bearing form is visible through said first space when said first information bearing form is positioned in said pocket, and a second space disposed therein whereby said information on said second information bearing form is visible through said second space when said second information bearing form is positioned in said second pocket.
 12. The apparatus of claim 8 wherein said third material is adhered to said transparent material along two intersecting edges thereof, whereby said second pocket is formed by said intersecting edges and said materials. 